A New Procedure of Esophagostomy for Endoscopic Surgeons

Hideto Oishi, MD PhD, Mina Miyashita, MD PhD, Takayuki Iino, MD, Takao Yamane, MD, Eiichi Hirai, MD PhD, Shingo Kameoka, MD PhD. Division of Gastroenterological Surgery, Yachiyo Medical Center, Tokyo Women’s Medical University

Introduction and objective;
This is the first case report of a new remodeling procedure of percutaneous trans-esophageal gastro-tubing (PTEG) for endoscopic surgeons using a vein visualization device, a noncontact type infrared rays. In 1994, PTEG was invented for cases with difficulty to create a percutaneous endoscopic gastrostomy (PEG). A rupture-free balloon (RFB) was invented for it in 1997. Its standard procedure using RFB had two technical parts. One was an esophagostomy under ultrasonic control, and the other was a tube placement under fluoroscopic control. These were new non vascular interventional radiological techniques with non surgical technique and with no endoscopic technique, too. We already performed this standard procedure for total of 185 cases, which included 97 cases of enteral nutrition and 88 cases of gastrointestinal decompression. Our achievement was admired as one of minimally invasive surgery, and now in Japan, there are already over 16,000 PTEG cases. However there was still a problem which should be improved. Basically PTEG was invented as one of alternative method for PEG, however the standard PTEG procedure needed no endoscopist. From 2003, we started to improve the PTEG procedure for endoscopic surgeons. Our aim was development of an endoscopic PTEG procedure without ultrasonogram nor fluoroscope.
Material and Method;
Using endoscope, we performed PTEG procedure to total of 68 cases without any complications, which included 51 cases of enteral nutrition and 17 cases of gastrointestinal decompression. We improved PTEG procedure for endoscopic surgeons, and we invented two items for this procedure. One of items was called needle holder pusher, NHP for short, and the other was called double balloon equiped overtube type RFB, DBOt-RFB for short. First, insert the endoscope covered with DBOt-RFB into cervical esophagus, and inflate its balloons. Push a puncture site of patient’s cervical surface with a penlight, and adjust balloons toward transmitted light by the endoscopic view. Push the puncture site by a NHP again, and check the transmitted light of endoscope. Keep pushing by the NHP, and illuminate the puncture site by the noncontact vein visualization device, and check a jugular vein. Keep a puncture site away from the jugular vein, and aim to transmitted light of endoscope, and puncture it by a needle. Check a tip of the needle by endoscopic view, and insert a guide wire through the needle into the esophagus. Dilate the puncture site by a dilator, and insert an indwelling tube, and check the tube placement by endoscopic view.
Results;
Using an endoscope, the DBOt-RFB, the HNP and the vein visualization device, a noncontact type infrared rays, an esophagostomy could be performed with no ultrasonogram. Using an endoscope, a tube placement could be performed with no fluoroscope, too. By the endoscopic view, we were able to maintain endoluminal informations of dilation and tube placement throughout the process. There were no complications, for example bleeding, mucosal injury, etc.
Expectations;
It can be performed at bed side without X-ray exposure, and moreover endoscopic view gives more safety.